High PSA, but MRI is negative. Biopsy or Not?

Hi, I would suggest you not count on MRI as being completely accurate. My PSA was continuing to elevate and I had 3 different MRIs at 3 different locations (2 of them 'Centers of Excellence) over a 2 year period. PIRAD 2 is what was resulted. My PSA reached 8 and I decided to go with a biopsy regardless of the MRIs. Turned out I had PCa with a 4+3 (7) upon biopsy. After moving forward with a Prostatectomy, we learned it had spread into the seminal vesicles. T3b. Bottom line for me is; my prostate had extensive PCa and it was missed on all MRIs. I could have gotten to it 2 years earlier. Just my opinion/experience. Having the biopsy was not a big deal in my opinion. Then you know for sure. Only way.
Best, Tom

At age 68 with a PSA that has more than doubled in five years, for a type of cancer that grows slowly, I would absolutely have the ultrasound-guided, trans-rectal, 12-core biopsy. I would not repeat the MRI. I am actually surprised by the number of men that say that they had the MRI - whether it was positive or negative. An MRI is a very expensive way to determine "presence or absence" of a potential tumor, but it says nothing of the category of your potential cancer like a biopsy will with the Gleason Score. Just remember...in this beginning phase of what could be a long journey, even the biopsy and Gleason Score are just the tip of a very large iceberg lurking below the surface. The biopsy will say whether you have cancer, and the Gleason Score will tell you "to what degree" it is developed in its pathology. If you have cancer, the lowest score you will get is a Gleason Score of 3 + 3 = 6, which is low risk (caught it early). You get two additive scores of the pathologist rating/categorizing the maturity/type of cells (s)he sees on two "passes" (complete views) of each of the 12 biopsy core tissue sample slides. They scan and identify what the predominant cell type is, say, "3". Then they scan again for the second-most predominant cell type. It could be a "4". So your score would be a 3 + 4 = 7 moderate risk cancer. You can also have "4" cells be the predominant cell type, and the second most predominant as 3, so your Gleason Score will be a 4 + 3 = 7, which is a high-moderate risk cancer. That cancer is further along in its pathology than a tumor that is a 3 + 4. You might also be a 4 + 4 = 8, or a 4 + 5 = 9, or a 5 + 4 = 9, etc. Example, former president Biden is a Gleason 9 (we don't know if it is a 4 + 5 =9 or a 5 + 4 = 9) which is very advanced either way.
Most importantly too, is to have your urologist order the Decipher Test on your biopsied tissue. The Decipher Test is a proprietary test developed by Veracyte Labs in San Diego, CA. They are the only lab that does the test. It is a genetic test that screens for the presence of any of what are 22-prostate-cancer-specific genes. You will receive a test report with a Decipher Test "score" of 0.1 to 1.0. You want that score to be as low as possible. The higher the score, the greater the number of genes you have...and it relates to the genes you have and how they will affect and determine your risk of mortality at 5 years, 10 years, and 15 years. The purpose is to help your physician plan a course of treatment/therapeutics based on what genes you have and how the prostate cancer with those genes will progress - and how rapidly. It is approved by Medicare as a 22-gene genetic test with its own CPT code 81542. Good luck...keep us posted as to your progress.

totally agree with the point about sustainability and finding an approach that is prostate healthy and somewhat enjoyable. I’ve even come to enjoy a few N/A beers but every once in awhile I have a regular beer and glass of wine. It’s been a year of adjustments.

@ezupcic Thanks!!

I’ve currently settled into running three “Zone 2” 5K’s every week (with the occasional 10K). I currently target a 10:00 minute pace and maintain an average heart rate of ~125 bpm.

I’ve been doing this for the last nine months. My VO2 Max has been holding pretty steady, in the 49-50 range, for the last 3 months.

I eat a cup or so of my homegrown broccoli spouts everyday…..been doing that for 2 years….along with my daily unsweetened ceremonial grade Matcha tea (Jade).

It takes a while to find things that work for you and that you really enjoy….it’s all about long term sustainability…IMHO short term “fixes” are pretty well useless when it comes to long term benefits.

My PSA jumped from 4 to 7.1 and my MRI was negative. My urologist had me take a free PSA blood test that showed up to a 50% chance of PC. He also explained that some men have clean MRIs but still have dangerous PC in their gland.

So we did a transrectal biopsy which revealed two PC cores - one Gleeson 3+4 and the other intermediate 4+3. Went ahead with IMRT + one HDR boost procedure + 6 months ADT. I am now 6 months post treatment and feeling almost back to 100%. Next PSA is early January...hoping my 0.04 level stays low

@ezupcic broccoli sprouts!

@handera, appreciate that. How is your running going? I’ve added brussel sprouts to my routine based on a post of yours I believe. Also some spin cycling to my workouts and moved my running to a treadmill for a bit. take care.

@ezupcic

Personally, I wouldn’t pursue in the case you mention; but I’m sure there are those that might.

My personal significant negative side effect experience with a lot of biopsy cores (21 in my case) definitely clouds my opinion against a so called “saturation biopsy”…when there is nothing to target.

My opinion is also based on the strongly held medical opinion (in some circles) that “MRI invisible lesions” are undoubtedly small…. therefore why not wait until there is clear evidence of something to actually target, since PCa is generally slow growing.

I know others may strongly disagree, thinking a 2mm 4+5 lesion may be lurking just under the radar…

At the end of the day it’s all about one’s individual perspective of risk/reward.

All the best!

@beachflyer
For most of us the good news is that Scan negative PC is usually low grade Gleason 6, but for a small percentage of us it can be advanced which is why we need to gather all the information we can (including biopsies) prior to treatment and pay close attention to subtle clues. In my case occasional small brown spots in semen (hematuria) was a pretty good sign of trouble. Both my family physician (who is a friend) and Urologist dismissed the hematuria since my PSA was so low and scan was negative. I did not fit the medical and insurance bellcurve for treatment. We are all our own best advocate.

@handera would you say that a saturation biopsy is still a good way to go even when there are no focal lesions to target, a somewhat clear MRI (pirads 1 or 2), fluctuating psa, lower PSA density, enlarged prostate? or more diagnostic testing?